Version 2.67

87509-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]Active

Term Description

This panel should be used for CMS LCDS v4.00 Admission assessments performed between July 1, 2018 and September 30, 2020.
Source: Regenstrief LOINC

Panel Hierarchy
Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
Indent85636-9 Administrative Information
IndentIndent58198-3 Type of Record
IndentIndent54581-4 Facility Provider Numbers
IndentIndentIndent76468-8 National Provider Identifier (NPI)
IndentIndentIndent69417-4 CMS Certification Number (CCN)
IndentIndentIndent45398-5 State Medicaid Provider Number
IndentIndent85632-8 Type of Provider
IndentIndent54593-9 Assessment Reference Date. Observation end date {mm/dd/yyyy}
IndentIndent52455-3 Admission Date {mm/dd/yyyy}
IndentIndent52454-6 Reason for Assessment
IndentIndent85816-7 Patient Demographic Information
IndentIndentIndent54503-8 Legal Name of Patient
IndentIndentIndentIndent45392-8 First name
IndentIndentIndentIndent45393-6 Middle initial
IndentIndentIndentIndent45394-4 Last name
IndentIndentIndentIndent45395-1 Suffix
IndentIndentIndent45966-9 Social Security and Medicare Numbers
IndentIndentIndentIndent45396-9 Social Security Number
IndentIndentIndentIndent45397-7 Medicare number (or comparable railroad insurance number)
IndentIndentIndent45400-9 Medicaid Number
IndentIndentIndent46098-0 Gender
IndentIndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndentIndent59362-4 Race/Ethnicity 1..6
IndentIndentIndent54505-3 Language
IndentIndentIndentIndent54588-9 Does the patient need or want an interpreter to communicate with a doctor or health care staff?
IndentIndentIndentIndent54899-0 Preferred language
IndentIndentIndent45404-1 Marital Status
IndentIndentIndent52556-8 Payer Information 1..13
IndentIndent85815-9 Pre-Admission Service Use
IndentIndentIndent85398-6 Admitted From
Indent87215-0 Hearing, Speech, and Vision {mm/dd/yyyy}
IndentIndent85629-4 Comatose. Persistent vegetative state/no discernible consciousness
IndentIndent83250-1 Expression of Ideas and Wants
IndentIndent87503-9 Understanding Verbal and Non-Verbal Content
Indent85638-5 Cognitive Patterns
IndentIndent85649-2 Signs and Symptoms of Delirium (from CAM)
IndentIndentIndent85812-6 Acute Onset and Fluctuating Course
IndentIndentIndentIndent85634-4 Is there evidence of an acute change in mental status from the patient's baseline?
IndentIndentIndentIndent85630-2 Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and decrease in severity?
IndentIndentIndent85631-0 Inattention.Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
IndentIndentIndent85651-8 Disorganized thinking.Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
IndentIndentIndent85811-8 Altered Level of Consciousness
IndentIndentIndentIndent85646-8 Overall, how would you rate the patient's level of consciousness? Alert (Normal)
IndentIndentIndentIndent85655-9 Overall, how would you rate the patient's level of consciousness? Vigilant (hyperalert) or Lethargic (drowsy, easily aroused) or Stupor (difficult to arouse) or Coma (unarousable)
Indent88238-1 Functional Abilities and Goals
IndentIndent85642-7 Prior Functioning: Everyday Activities
IndentIndentIndent85071-9 Indoor Mobility (Ambulation)
IndentIndent83234-5 Prior Device Use 1..4
IndentIndent85667-4 Self-Care - Admission Performance
IndentIndentIndent83232-9 Eating
IndentIndentIndent83230-3 Oral hygiene
IndentIndentIndent83228-7 Toileting hygiene
IndentIndentIndent85652-6 Wash upper body
IndentIndent85661-7 Self-Care - Discharge Goal
IndentIndentIndent83231-1 Eating
IndentIndentIndent83229-5 Oral hygiene
IndentIndentIndent83227-9 Toileting hygiene
IndentIndentIndent85653-4 Wash upper body
IndentIndent87502-1 Mobility - Admission Performance
IndentIndentIndent83218-8 Roll left and right
IndentIndentIndent83216-2 Sit to lying
IndentIndentIndent83214-7 Lying to sitting on side of bed
IndentIndentIndent83212-1 Sit to stand
IndentIndentIndent83210-5 Chair/bed-to-chair transfer
IndentIndentIndent83208-9 Toilet transfer
IndentIndentIndent83204-8 Walk 10 feet
IndentIndentIndent83202-2 Walk 50 feet with two turns
IndentIndentIndent83200-6 Walk 150 feet
IndentIndentIndent83271-7 Does the patient use a wheelchair and/or scooter?
IndentIndentIndent83188-3 Wheel 50 feet with two turns
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
IndentIndentIndent83235-2 Wheel 150 feet
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
IndentIndent85660-9 Mobility - Discharge Goal
IndentIndentIndent83217-0 Roll left and right
IndentIndentIndent83215-4 Sit to lying
IndentIndentIndent83213-9 Lying to sitting on side of bed
IndentIndentIndent83211-3 Sit to stand
IndentIndentIndent83209-7 Chair/Bed-to-chair transfer
IndentIndentIndent83207-1 Toilet transfer
IndentIndentIndent83203-0 Walk 10 feet
IndentIndentIndent83201-4 Walk 50 feet with two turns
IndentIndentIndent83199-0 Walk 150 feet
IndentIndentIndent83187-5 Wheel 50 feet with two turns
IndentIndentIndent83236-0 Wheel 150 feet
Indent83237-8 Bladder and Bowel
IndentIndent83238-6 Bladder Continence
IndentIndent83242-8 Bowel Continence
Indent85635-1 Active Diagnoses
IndentIndent85633-6 Indicate the patient's primary medical condition category
IndentIndent52797-8 Other medical condition
IndentIndent83243-6 Comorbidities and Co-existing Conditions 1..33
Indent85644-3 Swallowing/Nutritional Status
IndentIndent54567-3 Height and Weight
IndentIndentIndent3137-7 Height (in inches) [in_us];cm
IndentIndentIndent3141-9 Weight (in pounds) [lb_av];kg
Indent85055-2 Skin Conditions
IndentIndent58214-8 Unhealed Pressure Ulcers/Injuries. Does this patient have one or more unhealed pressure ulcers/injuries?
IndentIndent83246-9 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
IndentIndentIndent54884-2 Number of Stage 1 pressure injuries {#}
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54950-1 Number of unstageable pressure injuries presenting as deep tissue injury {#}
Indent87521-1 Medications
IndentIndent57255-2 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
IndentIndent57281-8 Medication Follow-up: Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?
Indent87230-9 Special Treatments, Procedures, and Programs
IndentIndent83252-7 Special Treatments, Procedures, and Programs 1..6
IndentIndent87537-7 Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar or Continuous Positive Airway Pressure (CPAP) Breathing Trial) by Day 2 of the LTCH Stay
IndentIndentIndent87539-3 Invasive Mechanical Ventilation Support upon Admission to the LTCH
IndentIndentIndent87538-5 Assessed for readiness for SBT by day 2 of the LTCH stay
IndentIndentIndent87540-1 Deemed medically ready for SBT by day 2 of the LTCH stay
IndentIndentIndent87541-9 Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for SBT by day 2 of the LTCH stay?
IndentIndentIndent87542-7 SBT performed by day 2 of the LTCH stay
IndentIndent69339-0 Influenza Vaccine
IndentIndentIndent55019-4 Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
IndentIndentIndent58131-4 Date influenza vaccine received {mm/dd/yyyy}
IndentIndentIndent55020-2 If influenza vaccine not received, state reason: C

Fully-Specified Name

Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00
CMS Assessment

Basic Attributes

First Released
Version 2.63
Last Updated
Version 2.66
Order vs. Observation
Panel Type

LOINC FHIR® API Example - CodeSystem Request Get Info